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What You Need to Know about Birth Control while Breastfeeding

​Most moms who breastfeed exclusively experience lactational amenorrhea​, i.e., they stop having their periods during the time that they are breastfeeding exclusively. During lactational amenorrhea, a woman’s potential to ovulate is decreased. As a result, her chances of getting pregnant while breastfeeeding falls to about 0.5 to 2.0%.  

Given the changes that occur to a woman’s body following pregnancy and delivery, most women prefer to avoid getting pregnant until at least one year after the delivery of their last child. However, many moms worry that that it might not be safe for them to use any form of contraceptive method while breastfeeding. ​In fact, what many moms do not know is that most contraceptive methods are not considered harmful to their babies, although some are potentially harmful to milk supply.​ ​

The contraceptive methods listed below can be used my breastfeeding moms. Some of them should be used with caution so that milk production is not adversely affected. ​

Combined Hormonal Contraceptives​

These contain both estrogen and progesterone. Three types of combined hormonal contraceptives are currently available:

  • The combined oral contraceptives commonly known as “The Pill”
  • The contraceptive transdermal patch commonly known as skin patch (Ortho Evra®)
  • The contraceptive vaginal ring (e.g., Nuvaring®)

These hormonal contraceptives prevent conception via the following mechanism: (1) inhibiting the development of ovarian follicles and ovulation, (2) acting on cervical mucus and preventing the movement of sperm cells, and (3) acting on the uterine lining and making it unfavorable for implantation of the fertilized egg.

While combination contraceptives have been shown to be very effective when used consistently and correctly (failure rate of only 3 pregnancies per 1,000 women per year), breastfeeding women have to use these with caution. There is evidence that estrogen-containing contraceptives can cause decreased milk production. Consequently, women who have problems with milk letdown and those who are breastfeeding children aged 1 year or more should exercise a lot of caution when taking combined hormonal contraceptives. In the bottom line, it is always best to consult your physician before starting any form of hormonal contraceptive when you’re breastfeeding.

In general, many physicians prefer to prescribe combination pills 5 to 6 weeks postpartum. This is mainly because these pills are more likely to cause the formation of blood clots during the first few weeks after childbirth. So, to circumvent this risk, it is advisable for new moms (even those who do not breastfeed their babies) to hold off using combination pills during the first 5 to 6 weeks after delivery.

Progestin-Only Contraceptives

These contraceptives contain only progesterone and are usually referred to as progestin-only contraceptives. Your physician is in the best position to tell you whether combination pills are better for you than the mini-pill.

​Most oby-gyns prefer a progestin-only contraceptive in breastfeeding women. These are commercialized under different names, including the “mini-pill” (a progestin-only oral contraceptive), Depo-Provera®​, Sayana Press®​, or Noristerat®​ (contraceptive injections), Mirena®​ or Skyla®​ (intrauterine devices that release progesterone), and Implanon®​ or Nexplanon®​ (contraceptive implants).

Action Duration of Different Long-Acting Progestin-Only Contraceptives

Depo-Provera®​:12 weeks but effects could last up to 12 months

Sayana Press®​: 13 weeks

Noristerat®​: 8 weeks

Mirena®​ : 5 years but effects could last up to 7 years

Skyla®​: 3 years

Implanon®​ : 3 years

Nexplanon®: 3 years

What You Should Do before Starting Progestin-Only Contraceptives

​Most breasfeeding women won’t have problems with their milk supply if progestin-only contraceptives are used 6 to 8 weeks after delivery, especially when prescribed at regular doses. Although there is no strong evidence that breastfeeding women might experience decreased milk letdown with these contraceptives, you should be vigilant when using them.

Before taking any of these longer acting progestin-only contraceptives, it is advisable to use a progestin-only pill for at least one month. If your milk supply decreases substantially when taking the mini-pill, then hormonal contraception might not be the best option for you. You can simply stop using the mini-pill (whose action is short-lasting) and opt for a more suitable contraceptive method. ​​

Do not start using any of the long-acting progestin-only contraceptives without performing a trial first. If you start with Depo-Provera®​, for example, and you experience low milk supply, the effects of the injection cannot be reversed. Thus, you would be struggling with milk supply for the next 12 weeks or more. Only use it after experimenting with a progestin-only oral contraceptive​. 

Barrier Methods

These methods block sperm from getting into the uterus. Some commonly used barrier methods include the diaphragm, cervical cap, male and female condom, spermicidal foam, sponges, and film. This method of contraception is only used prior to intercourse and it is important to follow the instructions of the manufacturer for the best results.

Why you might want to consider using a barrier method when breastfeeding

  • ​If you are worried about a method that uses hormone.
  • If hormonal contraceptives decrease your milk supply. 
  • If you are looking for a method that you can stop using whenever you want.
  • If you and your partner are comfortable using this method.

While barrier methods have no effect on milk production, they are less effective than other methods. Read more about the pros and cons of barrier methods here​.

Common Questions Asked by Breastfeeding Women

Will hormonal contraceptives decrease my milk supply?

As mentioned earlier, hormonal contraceptives, especially those that contain estrogen, can potentially decrease milk supply. In some women, milk supply is substantially decreased.

Will the hormone(s) in contraceptives affect my baby?

After searching the Cochrane database, MEDLINE, and EMBASE for all researches published on this topic, we did not find any report of adverse effects to the baby. However, there are concerns about using hormonal contraceptives when breasfeeding a baby less than 6 weeks old. At this age, a baby’s liver is not mature enough to metabolize the hormones passed through breast milk. But as mentioned earlier, physicians advise starting hormonal contraceptives at least 5 to 6 weeks after childbirth.

Does the use of hormonal contraceptives carry any risk in the mother?

Like all drugs, hormonal contraceptives have some risks associated with their use. These include, but are not limited to, the following:

  • Risk of developing venous thromboebolism (formation of blood clots in a vein).
  • Risk of myocardial infarction (a blockage in one or more of the arteries in the heart, resulting in a heart attack) and stroke.
  • Increased breast cancer risk.
  • ​Increased cervical cancer risk.

Can I use the morning-after pill when breastfeeding?

Morning after pills are sold either as a progestin-only pill or a combination pill containing the hormones estrogen and progesterone.​ Although the morning-after pill is considered safe in breastfeeding women, it should be used only when necessary (i.e., for emergency contraception).   

Medical disclaimer: The information provided here is intended to supplement, not substitute for, the expertise and judgment of your doctor or pharmacist. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects, nor should it be interpreted to indicate that use of any drug is safe, appropriate or effective for you or anyone else. Always consult your doctor or pharmacist before taking any drug, making modifications to your diet or starting or discontinuing your treatment.

References

  1. FSRH Healthcare Statement: Venous Thromboembolism (VTE) and Hormonal Contraception; Faculty of Sexual and Reproductive Healthcare, November 2014​.FSRH Healthcare Statement: Venous Thromboembolism (VTE) and Hormonal Contraception; Faculty of Sexual and Reproductive Healthcare, November 2014​.
  2. Sundaram A, Vaughan B, Kost K, et al. Contraceptive Failure in the United States: Estimates from the 2006-2010 National Survey of Family Growth. Perspect Sex Reprod Health. 2017 Mar;49(1):7-16.​​
  3. Raymond EG, Burke AE, Espey E. Combined hormonal contraceptives and venous thromboembolism: putting the risks into perspective. Obstet Gynecol. 2012 May 119(5):1039-44.
  4. de Bastos M, Stegeman BH, Rosendaal FR, et al. Combined oral contraceptives: venous thrombosis. Cochrane Database Syst Rev. 2014 Mar 3 3:CD010813.
  5. Roach RE, Helmerhorst FM, Lijfering WM, Stijnen T, Algra A, Dekkers OM. Combined oral contraceptives: the risk of myocardial infarction and ischemic stroke. Cochrane Database Syst Rev. 2015 Aug 27;(8):CD011054.​​
Princila M
 

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